Childhood TB: Clinical presentation of childhood tuberculosis

Childhood TB was written to enable healthcare workers to learn about the primary care of children with tuberculosis. It covers: introduction to TB infection, the clinical presentation, diagnosis, management and prevention of tuberculosis in children

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2 Clinical presentation of childhood tuberculosisBefore you begin this unit, please take the EARLY PRESENTATIONcorresponding test at the end of the book toassess your knowledge of the subject matter. OF TUBERCULOSISYou should redo the test after you’ve workedthrough the unit, to evaluate what you havelearned. 2-1 How is the clinical diagnosis of tuberculosis made? The clinical diagnosis of tuberculosis depends Objectives on the following five steps: 1. Having a high index of suspicion. When you have completed this unit you 2. The patient being in contact with an adult should be able to: with pulmonary tuberculosis. 3. Taking a careful history. • Recognise the general symptoms and 4. Completing a full general examination. signs of tuberculosis. 5. Requesting special investigations. • List the symptoms and signs of pulmonary tuberculosis. 2-2 What would make you suspect that • Describe the appearance of tuberculous the child may have tuberculosis? lymph node enlargement. Always suspect tuberculosis if one or more of • Clinically diagnose tuberculous the following are present: meningitis. • A history of close contact with someone • Clinically diagnose abdominal suffering from tuberculosis in the family or tuberculosis. household, especially if recently diagnosed. • Clinically diagnose spinal tuberculosis. • Poor, overcrowded living conditions. • Clinically diagnose disseminated • The child has HIV infection. tuberculosis. • The child is losing weight or is severely malnourished. • The child has a chronic, persistent cough.

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CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 25• The child has pneumonia which does not symptoms. In young children the parents respond to antibiotics. complain that the child is not as playful• The child has fever for more than 14 days as usual. Older children may complain of and is not responding to antibiotics. feeling weak and tired.• The child is unwell with vomiting and a • A fever for more then two weeks when decreased level of consciousness, with or no other cause of fever can be found and without convulsions. there is no response to antibiotics. Fever due to viral infections usually lasts lessHaving a high index of suspicion that the child than seven days.has been in close contact with someone with • Nights sweats, especially if the childtuberculosis in a community, especially if they is so wet that their clothes need to belive in the same household, is often the most changed. However severe night sweatsimportant step in making the diagnosis. A high are not common in young children withindex of suspicion is very important in the tuberculosis.early diagnosis of tuberculosis, as tuberculosis • Children with tuberculosis have usuallymay present in many different ways and may be been unwell for a few weeks when they firstconfused with a wide range of other diseases. present. Unlike the sudden onset in acute bacterial or viral infections, the symptoms Suspecting tuberculosis is important in making and signs of tuberculosis usually develop the diagnosis. over a number of days or weeks. • There are often no clinical signs on examination in the early stages of2-3 What are the symptoms and tuberculosis.clinical signs of tuberculosis? A detailed history is very important when• The early symptoms and signs of considering a diagnosis of tuberculosis as the tuberculosis are often vague and non- history is often the most important clue to the specific, making the diagnosis difficult. correct diagnosis. Therefore always consider These general symptoms and signs are tuberculosis in a child with a chronic cough, caused by tuberculosis at any site in the weight loss, failure to thrive or unexplained body. Children are usually asymptomatic fever for more than two weeks, especially in the early stages of tuberculosis. if there is an adult with a chronic cough or• The later signs of tuberculosis usually known pulmonary tuberculosis in the family. depend on which organ or organs are infected. The organ most commonly affected is the lung (pulmonary A careful history is very important in the tuberculosis). diagnosis of tuberculosis.Symptoms are what the child or parentcomplains of, while signs are what you observe. PULMONARY2-4 What are the early general TUBERCULOSISsymptoms and signs of tuberculosis?• Failure to thrive with poor weight gain or weight loss. Children with tuberculosis are 2-5 What are the symptoms of often thin and undernourished. This may pulmonary tuberculosis? first be noticed when the child’s weight is These symptoms and signs are important as plotted on the Road-to-Health card. pulmonary tuberculosis is the commonest• Feeling generally unwell with loss of form of tuberculosis in children and adults. appetite, apathy and fatigue, are common

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26 CHILDHOOD TB• In addition to the early general symptoms Commonly there are no clinical signs on chest and signs, the most important sign of examination in children with pulmonary pulmonary tuberculosis is a persistent cough lasting more than two weeks. The tuberculosis. cough may be dry or productive and shows no signs of improving. Children with tuberculosis may also have• The enlarged hilar nodes may press on symptoms and signs of HIV infection. a bronchus (airway) causing wheezing, cough or stridor. The wheeze does not respond to inhaled bronchodilators. EXTRAPULMONARY• Shortness of breath and fast breathing are not common in children with TUBERCULOSIS tuberculosis. Chest pain and blood-stained sputum (haemoptysis) may be present in 2-7 What is the clinical presentation adolescents, but are rare in children. of extrapulmonary tuberculosis? This depends on whether TB bacilli spread to A persistent cough lasting longer than two only one organ (e.g. the meninges), or to two weeks is an important symptom of pulmonary or more organs at the same time. tuberculosis.2-6 What are the clinical signs of ENLARGED TUBERCULOUSpulmonary tuberculosis? LYMPH NODES• Usually there are no abnormal clinical signs on examination of the chest. Therefore, a lack of signs does not exclude 2-8 What is the common site of the diagnosis of tuberculosis. enlarged tuberculous lymph nodes?• There may be signs of pneumonia (fast Enlarged lymph nodes (lymphadenopathy) breathing, crackles and decreased air due to tuberculosis occur most commonly in entry). the neck (cervical nodes).• There may be wheezing due to airway compression by enlarged hilar lymph nodes. The wheeze does not respond to Enlarged cervical lymph nodes may be due to bronchodilators. tuberculosis.• There may be signs of a pleural effusion (dullness over one side of the chest with 2-9 What are important signs of poor air entry and possibly shortness of enlarged cervical lymph nodes? breath), especially in older children and adolescents. Often the mother first notices that the child• Often children with extensive tuberculosis has lumps in the neck. At first the nodes are are not acutely ill, do not require typically firm and non-tender on examination. supplementary oxygen and have very few Later they may feel matted (stuck together). clinical signs on chest examination but Enlarged tuberculous lymph nodes may lead have extensive changes on chest X-ray. to complications.

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CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 272-10 What are the complications of Depressed level of consciousness is an importantenlarged cervical lymph nodes? sign of tuberculous meningitis.The lymph nodes may become tender and softdue to inflammation and the breakdown of It is important to suspect tuberculoustissue in the node (lymphadenitis) to form a meningitis in any child with drowsiness,lymph node abscess. Later lymph nodes may headache and vomiting. The onset of symptomsbecome attached to the skin and discharge and signs are often slow over a number of days.the soft (caseous) material onto the skin. This A depressed level of consciousness, convulsionsresults in a fistula. With healing, tuberculous and paralysis are late and dangerous signs.fistulas leave scars. 2-14 Do children with tuberculous2-11 What is a common cause of meningitis always die?enlarged lymph nodes in the axilla? It depends on whether the diagnosis is madeEnlarged lymph nodes in the axilla (arm pit) early or late. Full recovery is possible after anare common a few weeks or months after a early diagnosis. However children who presentBCG immunisation on the upper arm on the late with depressed level of consciousness andright side. This is not caused by tuberculosis signs of a stroke often die despite treatment.but results from the BCG immunisation in Children who survive after the developmentyoung children. Complications of enlarged of late signs may survive with permanentaxillary lymph nodes due to BCG are common disability (blindness, deafness, cerebral palsy,in children with HIV infection. mental retardation and hydrocephalus). It is very important to suspect TB meningitisTUBERCULOUS in any child with unexplained drowsiness, headache or vomiting so that an early diagnosisMENINGITIS can be made and immediate treatment started.2-12 What is tuberculous meningitis? ABDOMINALInfection of the membranes which cover the TUBERCULOSISbrain (the meninges) by TB bacilli.2-13 What is the clinical presentation 2-15 What is abdominal tuberculosis?of tuberculous meningitis? Tuberculosis of one or more organs in theThe symptoms and signs of tuberculous abdomen. It is usually due to the spread of TBmeningitis are: bacilli from the lungs. Newborn infants may• Drowsiness, irritability and vomiting in a have abdominal tuberculosis as a result of TB child who has been unwell for a few days. bacilli spreading from the infected placenta.• Depressed level of consciousness.• Older children may complain of headaches. 2-16 What are the clinical signs• Convulsions. of abdominal tuberculosis?• The fontanelle may be full with a rapidly The most common presentation of abdominal increasing head circumference. tuberculosis is:• Muscle weakness progressing to one-sided paralysis (hemiplegia) due to a stroke. • Abdominal distension (swelling). This may be due to fluid (ascites) or enlarged lymphOn examination there may be neck stiffness.

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28 CHILDHOOD TB nodes. The liver and spleen may also be DISSEMINATED enlarged.• Abdominal pain may be present. TUBERCULOSIS• Weight loss.• Fever with no obvious cause. 2-20 What is disseminated tuberculosis? Disseminated tuberculosis occurs when TBTUBERCULOUS BONE bacilli spread throughout the body via theAND JOINT DISEASE bloodstream as the immune system cannot contain them in the lung. This leads to tuberculosis in a number of organs other than2-17 What bones and joints may the lungs, such as the meninges, abdominalbe infected with TB bacilli? lymph nodes, liver, spleen, bones and joints.The most common sites are the spine (spinaltuberculosis) and large joints such as the hip, 2-21 Which children are at high riskknee or ankle. However, any bone or joint can of disseminated tuberculosis?be infected. • Children under the age of one year • Children who have not had BCG2-18 When do children develop immunisationbone tuberculosis? • Children with severe malnutritionBone tuberculosis (tuberculous osteitis) • Children with HIV infectionusually develops months to years after theprimary TB infection. It is due to reactivation Disseminated tuberculosis is most often seen inof TB bacilli that have been dormant in the infants.bone ever since they were first carried thereby blood spread from the lungs. Therefore itis uncommon in young children and usually 2-22 What is the clinical presentationseen in older children and adolescents. of disseminated tuberculosis? • At first the child becomes generally2-19 What is the presentation unwell with loss of appetite, failure toof spinal tuberculosis? thrive and fever. • There may be a history of cough.Tuberculous osteitis of the spine usually • The liver and spleen may be enlarged.occurs in the lower thoracic or upper lumbar • There may be features of tuberculousvertebrae with: meningitis.• Local pain and tenderness• Local deformity (gibbus) 2-23 Why is it important to• Spinal cord compression (difficulty diagnose disseminated tuberculosis walking and passing urine) as soon as possible?Any child with local pain and tenderness over Because these children become extremelythe spine must be suspected of having spinal ill and may die if not diagnosed and treatedtuberculosis. A rapid onset of a gibbus (‘hump rapidly and correctly.back’) is almost always due to tuberculosis. 2-24 What is miliary tuberculosis? Spinal tuberculosis presents with local pain and Miliary tuberculosis is the spread of TB bacilli tenderness. throughout both lungs. It is seen in some

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CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 29cases of disseminated tuberculosis and can be tuberculosis. You should also ask aboutdiagnosed on chest X-ray. overcrowding and poverty. NOTE The word ‘miliary’ comes from the Latin for millet seed as the X-ray in a 3. Why is the history of the child with miliary tuberculosis shows mother’s death important? small spots throughout both lungs. She might have died of tuberculosis complicating HIV infection. If the child is HIV positive this would greatly increase theSCORING SYSTEMS TO risk of tuberculosis.IDENTIFY TUBERCULOSIS 4. What clinical signs would you expect to find?2-25 Can a scoring system be used to helpmake a clinical diagnosis of tuberculosis? Often there are very few clinical signs early in tuberculosis. It would be important to weighScoring methods are available, but they are the child and plot the weight on the Road-not very accurate in children, especially if to-Health chart to assess weight loss. Signs ofHIV infection is also present. However, they malnutrition and HIV infection should also beare useful in identifying children who are at looked for.high risk of having tuberculosis and need to bereferred for further evaluation and special tests. 5. Do children with tuberculosis often have night sweats?CASE STUDY 1 No.A grandmother presents at a primary-care 6. Would a scoring system be usefulclinic with her three-year-old granddaughter. in diagnosing tuberculosis?She gives a history that the child has a poor It would be more accurate to identify childrenappetite, weight loss and fever for the past who are at high risk of tuberculosis and needthree weeks. The local general practitioner further investigation.prescribed amoxicillin for a respiratory tractinfection but this has not helped. The motherdied of HIV infection a few months ago. CASE STUDY 21. Why should you suspect tuberculosis? A four-year-old child presents with a chronicBecause the child has a number of the general cough for the past month, together withsymptoms which suggest tuberculosis (poor feeling weak and tired. As the examinationappetite with weight loss and prolonged fever). of the chest is normal, the medical officerFailure to respond to the antibiotic treatment assures the parents that the child does not havegiven for a bacterial respiratory tract infection pulmonary tuberculosis.also suggests tuberculosis. 1. Could this child have2. What social history would be important? pulmonary tuberculosis?It would be important to know if anyone Yes. A chronic cough, especially if notin the home has tuberculosis or a chronic improving, should always suggest tuberculosis.cough which may be due to undiagnosed There is not enough information to exclude tuberculosis.

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30 CHILDHOOD TB2. Would a normal chest examination 3. What complication can occur inexclude pulmonary tuberculosis? tuberculous lymph node enlargement?No, as children with pulmonary tuberculosis The nodes may become painful and softoften do not have abnormal chest signs on (lymphadenitis) and form an abscess or fistulaexamination. which drains onto the skin.3. What would be the likely cause 4. What may cause enlargedif a wheeze was present? axillary (arm pit) lymph nodes?If the child had no previous history of BCG immunisation on that side.wheezing, it would be important to think of anenlarged hilar lymph node pressing on a large 5. How do TB bacilli reachairway. If this were correct, the wheeze would the cervical nodes?not respond to an inhaled bronchodilator. By lymphatic spread from lymph nodes in the chest.4. What would the likely diagnosis be ifthere was poor air entry and dullness topercussion on one side of the chest? CASE STUDY 4A pleural effusion. This might also causeshortness of breath. An ill six-month-old child presents with a two-week history of fever, poor feeding,5. How should this child be managed? drowsiness and irritability. A few hours backFurther investigations are indicated to confirm the child had a convulsion. The father startedor exclude a clinical diagnosis of tuberculosis. on TB treatment a month before. 1. What is the likely clinical diagnosis?CASE STUDY 3 Tuberculous meningitis. The father is almost certainly the source of the infection.A ten-year-old girl is seen in the outpatientdepartment of a district hospital with a 2. How do TB bacilli reach the meninges?swelling in her neck. Examination suggestsenlarged cervical lymph nodes. There is no They get there via the bloodstream.history of tuberculosis in the home. Tuberculous meningitis is usually seen in infants and young children, and occurs soon after the primary infection.1. How common are enlarged cervicallymph nodes in tuberculosis? 3. Is it important that this child has had a fit?Cervical lymph node enlargement is commonin children with tuberculosis. Yes, as this is a late and serious sign of tuberculous meningitis and increases the risk of death or permanent disability. Therefore it2. What are the typical clinical findings? is important to make the diagnosis as soon asUsually the lymph nodes are firm and painless, possible.but may feel matted (stuck together).

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CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 314. What is miliary tuberculosis? 2. Children who are unwell with a chronic cough or weight loss should be investigatedDisseminated tuberculosis with widespread for tuberculosisinvolvement of both lungs. These children are 3. A normal clinical examination does notseriously ill. exclude tuberculosis in a child. 4. Tuberculous meningitis is a very serious5. What are important local signs form of tuberculosis and should beof abdominal tuberculosis? suspected in any child with lethargy,Abdominal pain and distension. Sometimes an headache and vomiting.enlarged liver and spleen may be palpated. 5. Disseminated tuberculosis is most commonly seen in young infants and children with HIV infection orTHE FIVE MOST malnutrition.IMPORTANT ‘TAKE-HOME’ MESSAGES1. Close contact with a person with untreated tuberculosis in the household is the most important clue to suspecting tuberculosis in a child.